Provider Demographics
NPI:1780988428
Name:JERNAGAN, ELIZABETH A (MSN, RN)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:A
Last Name:JERNAGAN
Suffix:
Gender:F
Credentials:MSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 W OLD KEY DR
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970
Mailing Address - Country:US
Mailing Address - Phone:765-475-6963
Mailing Address - Fax:
Practice Address - Street 1:315 W OLD KEY DR
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-9057
Practice Address - Country:US
Practice Address - Phone:765-475-6963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003534363LF0000X
IN28151141A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program